Sample Certificate of Destruction

Facility Name

The information described below was destroyed in the normal course of business pursuant to a proper retention schedule and destruction policies and procedures.

  Date of destruction:______________________________

Description of records or record series disposed of:
________________________________________________________________
________________________________________________________________

Inclusive dates covered:__________________________________________

Method of destruction:
( ) Burning ( ) Shredding ( ) Pulping ( ) Demagnetizing
( ) Overwriting ( ) Pulverizing ( ) Other:________________________

Records destroyed by:___________________________________________

Witness signature:______________________________________________

Department manager:_____________________________________________

Note: This sample form is provided for discussion purposes only. It is not intended for use without advice of legal counsel.


Source: AHIMA Practice Brief "Destruction of Patient Health Information" (updated November 2002)